Dealing with hate in mental health services

As you know, when we run relational security development sessions, we talk about boundaries. We take each boundary and discuss whether it’s non-negotiable (so, under no circumstances should the event occur), negotiable (there’s probably a rule, but under a certain set of circumstances, you’d apply your judgement) or whether it’s a ‘grey area’ and therefore up for discussion. The point is about staff talking together about these issues. Some are easy and some are hard. Connecting with a patient on Facebook? Easy! Non-negotiable. Doing your own shopping on escorted leave? Nope - definitely not.

But if you allow a pause to gestate, what can often follow is an unsatisfied silence until someone with a little courage says: “But we do, don't we? It happens. And we don't always know what to do about it”.

In not knowing what to do when a patient racially abuses a colleague, we run the risk of unwittingly endorsing those attitudes, failing the people we employ and neglecting the people we care for. Just writing a zero tolerance policy, breathing a sigh of relief and considering the issue dealt with isn’t enough.

Here’s an example. It’s a personal example actually; which is weird because I’m white. Well, not actually white. Kind of a grayish blue colour – more like a Smurf.

Anyway, last year (before she finally passed away aged 96) my parents were contacted by the care agency that visited my (step) grandmother daily. She’d dismissed one of the carers saying she didn’t “want any of you foreign girls touching me”. The agency advised my parents that this was considered unacceptable and if the personal assaults continued, they’d have no choice other than to withdraw their service.

Fair enough. No one should go to work and expect to have to endure personal slights and attacks on their identity. And no employer should feel like they can’t stand up for the rights and dignity of their staff. I was kind of pleased.

My parents though, were hopping mad.

How dare they? That’s what they’re paid for isn’t it? To look after someone who has dementia? She doesn't mean it; she doesn't even know what she’s saying. (I have an unhappy feeling that while she may have not been aware of what she was saying – it probably did reflect her attitudes).

My father (surprisingly, because I’ve always considered him a liberal chap) was bewildered. He reflected on his own career as a police officer and the countless times he’d been assaulted on the job. To be fair, he has. He’s had at least three broken noses, been chucked out a plate glass window and been bitten by his own police dog (though I think that was probably his fault). In his opinion, there are just some things you just have to ‘suck it up and accept’ in a job.

And here, I think, lies part of the misunderstanding about the problem. You see, while my father shouldn’t have been attacked because of his job, no police officer should, or any nurse in A&E or a paramedic responding in town on a Friday night, the attacks in his case were often on the institution and function he represented. He could return to the station to strength in numbers, unity, comradeship and support. He wasn’t alone. What wasn't being attacked, in his case, was the very fabric of his identity, the things about him that were core and unchangeable. And that’s different. Well, it feels different to me.

Here’s a better example. I met a healthcare worker in London a few months ago. You know how sometimes you meet a member of staff and think “If my kids get ill I want you to be the person that looks after them”? This was that guy. He worked in an adult woman's eating disorder service. A patient approached him one day with a toy monkey and said, “This is what your son will look like when he’s born”.

He was devastated. Even months later sitting with me, he was tearful and shaken by the experience. He’d raised the incident with his manager, who responded by moving him to work on a different ward pending an investigation (despite there being clear CCTV footage that should have shut the case down in about twenty minutes.) Two months (!) later he returned to his ward where the manager told him nothing could be done because the patient was mentally unwell. Unsurprisingly (and devastatingly considering how hard we work to find awesome staff) he’s looking for another job. You see, it wasn’t just the experience of racism that injured him – it was the whole experience of that plus how it was handled by his organisation. In dealing with these important issues, it’s not just a possibility that we’ll miss an opportunity to handle it well – there’s a real chance we can do someone harm.

It seems that we’re sometimes too quick, (though in this case – too slow) to offer the diagnosis of a patient as a defense for how someone’s been treated. In this case the staff member said, “I know she’s mentally unwell. I’ve just nursed her for six months; I’m not a complete idiot! But that doesn’t make it ok. It’s not ok for her, it’s not ok for me and it won’t be ok for someone else that comes into contact with her in the future”.

Another person I met worked with men with personality disorder. A patient refused to accept her escorting him on leave because he didn’t want to be seen with her because she’s black. The response of the service was to place another escort with the patient and explain that the patient is ‘old fashioned’ and ill and doesn’t know any better. Personally, I’d have cancelled his leave and told him exactly why, but that’s maybe just me.

I think the message here is - we know it’s complex. We’re required to provide services. We know we can’t withhold care in these settings and that often the mental status of the patient will have a bearing on the course of action we’re able to take. But let’s not leap to formulation as the first response. Let’s acknowledge first that it’s a vile thing to have happened, that it shouldn't have happened and let’s be clear about what action might have some therapeutic value, even if it’s only a very small thing in contrast with the gravity of the offence.

Here are a few themes that have emerged from relational security sessions over the last year or so, from talking to a few people in the system who’ve started some good work in this area (notably, Dr Paul Beckley of Avon & Wiltshire MHPT) and from a short workshop I ran with Michael Humes at the QNFMH annual forum this year:

We often don’t have good data relating to incidents of hatred or intolerance. I’ve picked up particularly on racism here, but obviously hatred is directed towards many characteristics in our flawed society. Anecdote is difficult to take seriously.

Our employee assistance program staff (if we have them) often don’t have the skills to meaningfully support staff who experience hatred. Sometimes this is because of a lack of corporate clarity on the issue.

Many ‘zero-tolerance’ policies (if they exist) don’t really have teeth. They don’t accept the likelihood that we will encounter hatred in this setting and set out how we’ll deal with it when we do.

Clinical strategies for services (again, where they exist) are silent on how such issues will be treated therapeutically. Some people will have deeply held beliefs that are impossible to shift. We can’t expect to be discharging perfect citizens with pro-social habits 100% of the time. But in deciding what our clinical strategies are, let’s also decide what our principles are in relation to building community skills in the people we care for and give our staff the confidence and skills to deliver on that principle. While people are in our care, is it incumbent on us to address hate crime as we do violent crime? If racism or any other kind of hatred remains part of a patient’s set of attitudes when they settle in the community, how likely is it that they’ll settle well?

Often staff seem to be moved away from an area or function which worsens feelings of being unfairly punished and sends entirely the wrong message back to the perpetrator.

Relationships with police are very variable. This is not a new discovery but it affects this issue as well as it does many others and frustrates attempts to meaningfully respond to ‘crimes in care’.

People from non-minority groups are often afraid of discussing this issue openly for fear of getting it wrong. For that reason, staff who do experience an incident of hatred can feel very alone. However we support services to deal with this, it must include opportunities for all staff to express any anxiety or lack of knowledge they have about the issues

Some younger staff I’ve encountered have been under the impression that it’s ok for older people to be racist because 40 years ago racism was ok. Terms like ‘outdated’, ‘old-fashioned’, ‘primitive’ etc. have no place in a discussion about racism. It was never ok.

So, to summarise; sometimes we have a problem with hatred towards our staff that we’re finding it hard to deal with satisfactorily. It feels especially difficult for our services because of issues relating to capacity and a clearer clinical narrative about possible therapeutic approaches to this issue might be really helpful for staff.